05 Methotrexate improve the foot functional impairment in juvenile idiopathic arthritis

Abstract Background Foot involvement in juvenile idiopathic arthritis (JIA) is common and affects about 60% of children [1]. Often overlooked by patients and practitioners, ankle and foot disability has been poorly studied and there are no accepted clinical practice guidelines for the diagnostic approach, as well as for the therapeutic management. Objectives Our study aimed to evaluate the effect of medical treatments on functional disability related to foot involvement in JIA. Methods We conducted a cross-sectional study including patients with JIA according to the revised ILAR criteria, collected from the rheumatology department of the Kassab National Institute. Sociodemographic and disease data (activity assessed by the Juvenile Arthritis Disease Activity Score 10 (JADAS-10) and therapeutic modalities) were recorded. Ankle and foot involvement were investigated by questioning and physical examination. We used the Oxford ankle foot questionnaire for children (OxAFQ-C); a validated, simple and reproducible score to assess the impact on the quality of life of children with foot problems [2]. This questionnaire encompasses 14 items corresponding to three dimensions: physical, school and play, and emotional. Higher scores represent better functioning. We searched for an association between the different drug treatments for JIA and the OxAFQ-C score. Results The study included 23 patients. The mean age was 13 ± 4 [6–18] years. The sex ratio was 0.42 with a female predominance. The age of the disease was 49 ± 40 months [6–180 months]. The distribution of the different forms of JIA was as follows: oligoarticular (n = 7), enthesitis-related arthritis (n = 6), polyarticular FR + (n = 1), polyarticular FR- (n = 3), psoriatic arthritis (n = 3), systemic (n = 1) and undifferentiated (n = 1). Pain on walking and limitation of the talocrural joint was found in 39% and 30% respectively. The mean JADAS-10 score was 6.72 ± 6.1 [0–20]. Ten patients had high activity. Eighteen patients (78%) were taking level I analgesics and 14 patients (61%) were on non-steroidal anti-inflammatory drugs, 12 of them on demand. Naproxen was the most commonly used drug, followed by diclofenac. Eleven patients (48%) were on a disease-modifying anti-rheumatic drug (csDMARD). Methotrexate (MTX) was prescribed in 30% of cases with a mean dose of 7.91 mg/week [7.5–10]. Only one patient was on sulfasalazine. Four patients (17%) were treated with biologics: Etanercept (n = 3) and Tocilizumab (n = 1). The mean scores of the different domains of (OxAFQ-C) were as follows: 73.52 ± 35.89 [0—100] in the physical domain, 84.2 ± 30 [6.25—100] in the school and play domain, 88.75 ± 24.71 [12.5 – 100] in the emotional domain. There was no statistically significant association between the different domains of the Oxford score and the use of analgesics or NSAIDs (p> 0.05). Similarly, there was no statistically significant association between the different domains of the Oxford score and treatment with biotherapy (p> 0.05). However, patients on MTX had less functional impairment of the feet with a significant improvement in the physical domain (99.26 on MTX vs 62.5 without MTX, p = 0.02, r = 0.6). Conclusion Our work showed that only methotrexate was associated with an improvement in functional foot outcomes in JIA. Further studies are needed to highlight the effect of other therapies, especially biologics. References [1] Arkell-Kautiainen M, Haapasaari J, Kautiainen H, Vilkkumaa I, Mälkiä E, Leirisalo-Repo M. Favourable social functioning and health-related quality of life of patients with JIA in early adulthood. Ann Rheum Dis. 2005; 64(6):875–880 [2] Morris C, Liabo K, Wright P and Fitzpatrick R. Development of the Oxford ankle foot questionnaire: finding out how children are affected by foot and ankle problems. Child: care and health development. 2007; 33(5): 559–68. The implication to policy, practice, research and advocacy More studies are needed regarding the effect of therapeutics on foot involvement in JIA children


Background
Foot involvement in juvenile idiopathic arthritis (JIA) is common and affects about 60% of children [1]. Often overlooked by patients and practitioners, ankle and foot disability has been poorly studied and there are no accepted clinical practice guidelines for the diagnostic approach, as well as for the therapeutic management.

Objectives
Our study aimed to evaluate the effect of medical treatments on functional disability related to foot involvement in JIA.

Methods
We conducted a cross-sectional study including patients with JIA according to the revised ILAR criteria, collected from the rheumatology department of the Kassab National Institute. Sociodemographic and disease data (activity assessed by the Juvenile Arthritis Disease Activity Score 10 (JADAS-10) and therapeutic modalities) were recorded. Ankle and foot involvement were investigated by questioning and physical examination. We used the Oxford ankle foot questionnaire for children (OxAFQ-C); a validated, simple and reproducible score to assess the impact on the quality of life of children with foot problems [2]. This questionnaire encompasses 14 items corresponding to three dimensions: physical, school and play, and emotional. Higher scores represent better functioning. We searched for an association between the different drug treatments for JIA and the OxAFQ-C score.

Results
The study included 23 patients. The mean age was 13 AE 4 [6-18] years. The sex ratio was 0.42 with a female predominance. The age of the disease was 49 AE 40 months [6-180 months]. The distribution of the different forms of JIA was as follows: oligoarticular (n ¼ 7), enthesitisrelated arthritis (n ¼ 6), polyarticular FR þ (n ¼ 1), polyarticular FR-(n ¼ 3), psoriatic arthritis (n ¼ 3), systemic (n ¼ 1) and undifferentiated (n ¼ 1). Pain on walking and limitation of the talocrural joint was found in 39% and 30% respectively. The mean JADAS-10 score was 6.72 AE 6.1 [0-20]. Ten patients had high activity. Eighteen patients (78%) were taking level I analgesics and 14 patients (61%) were on non-steroidal anti-inflammatory drugs, 12 of them on demand. Naproxen was the most commonly used drug, followed by diclofenac. Eleven patients (48%) were on a disease-modifying anti-rheumatic drug (csDMARD). Methotrexate (MTX) was prescribed in 30% of cases with a mean dose of 7.91 mg/week [7.5-10]. Only one patient was on sulfasalazine. Four patients (17%) were treated with biologics: Etanercept (n ¼ 3) and Tocilizumab (n ¼ 1). The mean scores of the different domains of (OxAFQ-C) were as follows: 73.  12.5 -100] in the emotional domain. There was no statistically significant association between the different domains of the Oxford score and the use of analgesics or NSAIDs (p> 0.05). Similarly, there was no statistically significant association between the different domains of the Oxford score and treatment with biotherapy (p> 0.05). However, patients on MTX had less functional impairment of the feet with a significant improvement in the physical domain (99.26 on MTX vs 62.5 without MTX, p ¼ 0.02, r ¼ 0.6).

Conclusion
Our work showed that only methotrexate was associated with an improvement in functional foot outcomes in JIA. Further studies are needed to highlight the effect of other therapies, especially biologics.

Background
Children with juvenile idiopathic arthritis (JIA) are less active compared with the general population due to pain and deformities, mainly of the lower limbs. Indeed, only 23% of children with JIA meet the public health recommendations of one h of moderate to vigorous physical activity daily [1]. In this context, foot involvement in JIA is a considerable limiting cause of physical activity.

Objectives
Our study aimed to investigate the types of static foot disorders that impede physical activity in children with JIA.

Methods
We conducted a cross-sectional study of patients with JIA according to the revised ILAR criteria. Socio-demographic and disease-related data were recorded. All patients underwent podoscope examination for varus or valgus deformity of the hindfoot and plantar footprint abnormality (flat foot or hollow foot). Patients with ankle or foot involvement due to congenital malformation or any other cause besides JIA were excluded. The impact of foot involvement on physical activity was assessed by the Oxford ankle foot questionnaire for children (OxAFQ-C). A higher score represents better functioning. We looked for the effect of foot abnormalities and their impact on physical activity. Results A total of 23 patients were collected. The mean age was 12.7 AE 3 [6-18] years and the mean age at diagnosis was 9.3 AE 3 [3-16] years. There was a female predominance with a sex ratio of 0.42. The majority of patients had secondary education (52%). The distribution of the different subtypes was dominated by the oligoarticular form (30%) and the enthesitis-related arthritis form (26%), followed by the polyarticular FR þ (n ¼ 1), polyarticular FR-(n ¼ 3), psoriatic arthritis (n ¼ 3), systemic (n ¼ 1) and undifferentiated (n ¼ 1) forms. The mean physical activity score assessed by the Oxford score was 73.52 AE 35.8 [0 -100]. Plantar footprint abnormalities of the hollow and flat foot were found in 39% and 30% of cases respectively. These abnormalities were unilateral and bilateral in 7 and 9 patients respectively. Eleven patients (48%) had a hindfoot abnormality and 30% of them had a limitation of joint movement range. There was no statistically significant association between the physical domain of the Oxford score and the presence of a limited range of the talocrural joint (p> 0.05). A significant reduction in physical activity was associated with hindfoot pain (5.37 vs 89.56; p< 0.001) but was not associated with the presence of hindfoot abnormalities (p ¼ 0.05). The presence of flat feet was significantly associated with impairment in all domains of the Oxford score, particularly in the physical domain (36.79 for the flat foot group vs 89.2 for the group without flat feet, p ¼ 0.001). However, the presence of a hollow foot did not lead to an alteration of the physical activity of JIA patients (p> 0.05).